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Acute Abdomen
Acute Abdomen
Acute Abdomen
Anatomy reviewNon-hemorrhagic abdominal painGastrointestinal hemorrhageAssessmentManagement
Abdominal Anatomy
Review
Abdominal Cavity
Superior border = diaphragm Inferior border = pelvisPosterior border = lumbar spine Anterior border = muscular
abdominal wall
Peritoneum
Abdominal cavity lining Double-walled structure
» Visceral peritoneum
» Parietal peritoneum
Separates abdominal cavity into two parts» Peritoneal cavity
» Retroperitoneal space
Primary GI Structures
Mouth/oral cavity» Lips, cheeks, gums, teeth, tongue
Pharynx» Portion of airway between nasal cavity and
larynx
Primary GI Structures
Esophagus» Portion of digestive
tract between pharynx and stomach
Stomach» Hollow digestive
organ
» Receives food from esophagus
Primary GI Structures
Small intestine » Between stomach and cecum» Composed of duodenum,
jejunum and ileum» Site of nutrient absorption
into body Large intestine
» From ileocecal valve to anus » Composed of cecum, colon,
rectum» Recovers water from GI tract
secretions
Accessory GI Structures
Salivary glands»Produce, secrete saliva
»Connect to mouth by ducts
Accessory GI Structures
Liver» Large solid organ in right upper quadrant » Produces, secretes bile » Produces essential proteins» Produces clotting factors» Detoxifies many substances» Stores glycogen
Gallbladder» Sac located beneath liver» Stores and concentrates bile
Accessory GI Structures
Pancreas» Endocrine pancreas secretes insulin into
bloodstream
» Exocrine pancreas secretes digestive enzymes, bicarbonate into gut
Vermiform appendix» Hollow appendage
» Attached to large intestine
» No physiologic function
Major Blood Vessels
Aorta Inferior vena cava
Solid Organs
LiverSpleenPancreasKidneysOvaries (female)
Hollow Organs
Stomach IntestinesGallbladder and bile ductsUretersUrinary bladderUterus and Fallopian tubes (female)
Right Upper Quadrant
LiverGallbladderDuodenumTransverse colon (part)Ascending colon (part)
Left Upper Quadrant:
StomachLiver (part)PancreasSpleenTransverse colon (part)Descending colon (part)
Right Lower Quadrant
Ascending colonVermiform appendixOvary (female)Fallopian tube (female)
Left Lower Quadrant
Descending colonSigmoid colonOvary (female)Fallopian tube (female)
Acute Abdomen
Abdominal Pain
VisceralSomaticReferred
Abdominal Pain
Visceral pain»Stretching of peritoneum or organ
capsules by distension or edema
»Diffuse
»Poorly localized
»May be perceived at remote locations related to organ’s sensory innervation
Abdominal Pain
Somatic pain» Inflammation of parietal peritoneum or
diaphragm
»Sharp
»Well-localized
Abdominal Pain
Referred pain»Perceived at distance from diseased organ
»Pneumonia
»Acute MI
»Male GU problems
Non-hemorrhagic Abdominal Pain
Esophagitis
Inflammation of distal esophagusUsually from gastric reflux, hiatal
hernia
Esophagitis
Signs and Symptoms»Substernal burning pain, usually epigastric
»Worsened by supine position
»Usually without bleeding
»Often temporarily relieved by nitroglycerin
Acute Gastroenteritis
Inflammation of stomach, intestineMay lead to bleeding, ulcersCauses
acid secretion»Chronic EtOH abuse»Biliary reflux»Medications (ASA, NSAIDS)» Infection
Acute Gastroenteritis
Signs and Symptoms»Epigastric pain, usually burning
»Tenderness
»Nausea, vomiting
»Diarrhea
»Possible bleeding
Chronic Infectious Gastroenteritis
Long-term mucosal changes or permanent damage
Due primarily to microbial infections (bacterial, viral, protozoal)
Fecal-oral transmission More common in underdeveloped countries Nausea, vomiting, fever, diarrhea, abdominal
pain, cramping, anorexia, lethargy Handwashing, BSI
Peptic Ulcer Disease
Craters in mucosa of stomach, duodenum
Males 4x > Females Duodenal ulcers 2 to 3x
> Gastric ulcers Causes:
» Infectious disease: Helicobacter pylori (80%)
» NSAIDS
» Pancreatic duct blockage
» Zollinger-Ellison Syndrome
Peptic Ulcer Disease
Duodenal Ulcers» 20 to 50 years old
» High stress occupations
» Genetic predisposition
» Pain when stomach is empty
» Pain at night
Gastric Ulcers» > 50 years old
» Work at jobs requiring physical activity
» Pain after eating or when stomach is full
» Usually no pain at night
Peptic Ulcer Disease
Complications»Hemorrhage
»Perforation, progressing to peritonitis
»Scar tissue accumulation, progressing to obstruction
Peptic Ulcer Disease
Signs and Symptoms»Steady, well-localized pain»“Burning”, “gnawing”, “hot rock”»Relieved by bland, alkaline
food/antacids»Worsened by smoking, coffee,
stress, spicy foods»Stool changes, pallor associated
with bleeding
Pancreatitis
Inflammation of pancreas in which enzymes auto-digest gland
Causes include:» EtOH (80% of cases)
» Gallstones obstructing ducts
» Elevated serum triglycerides
» Trauma
» Viral, bacterial infections
Pancreatitis
May lead to:»Peritonitis
»Pseudocyst formation
»Hemorrhage
»Necrosis
»Secondary diabetes
Pancreatitis
Signs and Symptoms»Mid-epigastric pain radiating to back»Often worsened by food, EtOH»Bluish flank discoloration (Grey-Turner
Sign)»Bluish periumbilical discoloration
(Cullen’s Sign)»Nausea, vomiting»Fever
Cholecystitis
Gall bladder inflammation, usually 2o to gallstones (90% of cases)
Risk factors
» Five Fs: Fat, Fertile, Febrile, Fortyish, Females
» Heredity, diet, BCP use
Cholecystitis
Acalculus cholecystitis» Burns
» Sepsis
» Diabetes
» Multiple organ systems failure
Chronic cholecystitis (bacterial infection)
Cholecystitis
Signs and Symptoms
»Sudden pain, often severe, cramping»RUQ, radiating to right shoulder»Point tenderness under right costal
margin (Murphy’s sign)»Nausea, vomiting»Often associated with fatty food intake»History of similar episodes in past»May be relieved by nitroglycerin
Appendicitis
Inflammation of vermiform appendix
Usually secondary to obstruction by fecalith
May occur in older persons secondary to atherosclerosis of appendiceal artery and ischemic necrosis
Appendicitis
Signs and Symptoms» Classic: Periumbilical pain RLQ pain/cramping
» Nausea, vomiting, anorexia
» Low-grade fever
» Pain intensifies, localizes resulting in guarding
» Patient on right side with right knee, hip flexed
Appendicitis
Signs and Symptoms» McBurney’s Sign: Pain on palpation of
RLQ
» Aaron’s Sign: Epigastric pain on palpation of RLQ
» Rovsing’s Sign: Pain in LLQ on palpation of RLQ
» Psoas Sign: Pain when patient:
– Extends right leg while lying on left side
– Flexes legs while supine
Appendicitis
Signs and Symptoms» Unusual appendix position may lead to atypical
presentations
– Back pain
– LLQ pain
– “Cystitis”
» Rupture: Temporary pain relief followed by peritonitis
Bowel Obstruction
Blockage of intestine Common Causes
» Adhesions (usually 2o to surgery)
» Hernias
» Neoplasms
» Volvulus
» Intussuception» Impaction
Bowel Obstruction
Pathophysiology» Fluid, gas, air collect near obstruction site
» Bowel distends, impeding blood flow/ halting absorption
» Water, electrolytes collect in bowel lumen leading to hypovolemia
» Bacteria form gas above obstruction further worsening distension
» Distension extends proximally
» Necrosis, perforation may occur
Bowel Obstruction
Signs and Symptoms» Severe, intermittent, “crampy” pain
» High-pitched, “tinkling” bowel sounds
» Abdominal distension
» History of decreased frequency of bowel movements, semi-liquid stool, pencil-thin stools
» Nausea, vomiting
» ? Feces in vomitus
Hernia
Protrusion of abdominal contents into groin (inguinal) or through diaphragm (hiatal)
Often secondary to intra-abdominal pressure (cough, lift, strain)
May progress to ischemic bowel (strangulated hernia)
Hernia
Signs and Symptoms
»Pain by abdominal pressure
»Past history
» Inguinal hernia may be palpable as mass in groin or scrotum
Crohn’s Disease
Idiopathic inflammatory bowel disease Occurs anywhere from mouth to rectum 35-45%: small intestine; 40%: colon Runs in families High risk groups
» White females
» Jews
» Persons under frequent stress
Crohn’s Disease
Pathophysiology» Mucosa of GI tract becomes inflamed
» Granulomas form, invade submucosa
» Muscular layer of bowel become fibrotic, hypertrophied
» Increased risk develops for
– Obstruction
– Perforation
– Hemorrhage
Ulcerative Colitis
Idiopathic inflammatory bowel disease Chronic ulcers develop in mucosal
layer of colon Spread to submucosal layer
uncommon 75% of cases involve rectum (proctitis)
or rectosigmoid portion of large intestine
Inflammation can spread through entire large intestine (pancolitis)
Ulcerative Colitis
Severity of signs, symptoms depends on extent
Classic presentation» Crampy abdominal pain
» Nausea, vomiting
» Blood diarrhea or stool containing mucus
Ischemic damage with perforation may occur
Diverticulitis
Diverticula» Pouches in colon
wall
» Typically in older persons
» Usually asymptomatic
» Related to diets with inadequate fiber
Diverticulitis
Diverticula trap feces, become inflamed Occasionally result in bright red rectal
bleeding Rupture may cause peritonitis, sepsis
Diverticulitis
Signs and Symptoms »Usually left-sided pain
»May localize to LLQ (“left-sided appendicitis”)
»Alternating constipation, diarrhea»Bright red blood in stool
Hemorrhoids
Small masses of veins in anus, rectum Most frequently develop when patients
are in 30s or 40s; common past 50 Most are idiopathic, can be associated
with pregnancy, portal hypertension Cause bright red bleeding, pain on
defecation May become infected, inflamed
Peritonitis
Inflammation of abdominal cavity liningSigns and Symptoms
»Generalized pain, tenderness
»Abdominal rigidity
»Nausea, vomiting
»Absent bowel sounds
»Patient resistant to movement
Hemorrhagic Abdominal Problems
Gastrointestinal Hemorrhage
Intraabdominal Hemorrhage
Esophageal Varices
Dilated veins in esophageal wall
Occur 2o to hepatic cirrhosis, common in EtOH abusers
Obstruction of hepatic portal blood flow results in dilation, thinning of esophageal veins
Esophageal Varices
Portal hypertension» Hepatic scarring
slows blood flow
» Blood backs up in portal circulation
» Pressure rises
» Vessels in portal circulation become distended
Esophageal Varices
Signs and Symptoms
»Hematemesis (usually bright red)
»Nausea, vomiting
»Evidence of hypovolemia
»Melena (uncommon)
Mallory-Weiss Syndrome
Longitudinal tears at gastroesophageal junction
Occur as result of prolonged, forceful vomiting, retching
Common in alcoholics May be complicated by
presence of esophageal varices
Peptic Ulcer Disease
Ulcer erodes through blood vesselMassive hematemesisMelena may be present
Aortic Aneurysm
Localized dilation due to weakening of aortic wall
Usually older patient with history of hypertension, atherosclerosis
May occur in younger patients secondary to
»Trauma
»Marfan’s syndrome
Aortic Aneurysm
Usually just above aortic bifurcation
May extend to one or both iliac arteries
Aortic Aneurysm
Signs and Symptoms»Unilateral lower quadrant pain; low back
or leg pain»May be described as tearing or ripping»Pulsatile palpable mass usually above
umbilicus»Diminished pulses in lower extremities»Unexplained syncope, often after BM»Evidence of hypovolemic shock
Ectopic Pregnancy
Any pregnancy that takes place outside of uterine cavity
Most common location is in Fallopian tube
Pregnancy outgrows tube, tube wall ruptures
Hemorrhage into pelvic cavity occurs
Ectopic Pregnancy
Suspect in females of child-bearing age with: » Abdominal pain, or
» Unexplained shock
When was last normal menstrual period?
Ectopic pregnancy does NOT necessarily cause missed period
Assessment of Acute Abdomen
History
Where do you hurt?
» Try to point with one finger
What does pain feel like?» Steady pain = Inflammatory process
» Cramping pain = Obstructive process
Onset of pain?» Sudden = Perforation or vascular occlusion
» Gradual = Peritoneal irritation, distension of hollow organ
History
Does pain travel anywhere?» Gallbladder = Angle of right scapula
» Pancreas = Straight through to back
» Kidney/ureter = Around flank to groin
» Heart = epigastrium, neck/jaw, shoulders, upper arms
» Spleen = Left scapula, shoulder
» Abdominal Aortic Aneurysm = low back radiating to one or both legs
History
How long have you been hurting?» >6 hours = increased probability of surgical
significance
Nausea, vomiting» How much, How long?
– Consider possible hypovolemia
» Blood, coffee grounds?
– Any blood in GI tract = emergency until proven otherwise
History
Urine»Change in urinary habits?
–Frequency
–Urgency
»Color?
»Odor?
History
Bowel movements»Change in bowel habits? Color? Odor?
–Bright red blood
–Melena = black, tarry, foul-smelling stool
–Dark stoolSuspect bleedingOther causes possible (iron or bismuth
containing materials)
History
Last normal menstrual period? Abnormal bleeding? In females, lower abdominal pain =
GYN problem until proven otherwise In females of child-bearing age, lower
abdominal pain = ectopic pregnancy until proven otherwise
Physical Exam
Position and General Appearance»Still, refusing to move = Inflammation,
peritonitis
»Extremely restless = Obstruction
Gross appearance of abdomen»Distended
»Discolored
»Consider possible third spacing of fluids
Physical Exam
Vital signs»Tachycardia = more important sign of
volume loss than falling BP
»Rapid, shallow breathing = possible peritonitis
»Consider performing “tilt” test
Physical Exam
Bowel sounds»Auscultate BEFORE palpating
»One minute in each abdominal quadrant
»Absent sounds = possible peritonitis, shock
»High-pitched, tinkling sounds = possible bowel obstruction
Physical Exam
Palpation»Palpate each quadrant
»Palpate area of pain LAST
»Do NOT check rebound tenderness in prehospital setting
»ALL abdominal tenderness significant until proven otherwise
Management
Oxygen by non-rebreather mask IV LR or NSPASG (demonstrated benefit in
intrabdominal hemorrhage)Keep patient from losing body heatMonitor vital signs
Management
Monitor EKG
Keep patient npo Analgesia controversial Demerol is preferred narcotic analgesic
Consider possible MI with pain referred to abdomen in patients >30 years old
